Early detection of psychosis: finding those at clinical high risk

Mapping Psychosis Risk States onto the Hierarchical Taxonomy of Psychopathology Using Hierarchical Symptom Dimensions

Clinical high risk for psychosis (CHR) is a transdiagnostic risk state. However, it is unclear how risk states such as CHR fit within broad transdiagnostic models such as the Hierarchical Taxonomy of Psychopathology (HiTOP). In this study, a hierarchical dimensional symptom structure was defined by unfolding factor analysis of self-report data from 3,460 young adults (mage=20.3). A subsample (n=436) completed clinical interviews, 85 of whom met CHR criteria. Regression models examined relationships between symptom dimensions, CHR status, and clinician-rated symptoms. CHR status was best explained by a reality distortion dimension, with contributions from internalizing dimensions. Positive and negative attenuated psychotic symptoms were best explained by multiple psychotic and nonpsychotic symptom dimensions including reality distortion, distress, fear, detachment, and mania. Attenuated psychotic symptoms are a complex presenting problem warranting comprehensive assessment. HiTOP can provide both diagnostic precision and broad transdiagnostic coverage, making it a valuable resource for use with at-risk individuals.

Sampling from different populations: Sociodemographic, clinical, and functional differences between samples of first episode psychosis individuals and clinical high-risk individuals who progressed to psychosis

Over the past two decades, research and clinical resources on clinical high risk (CHR) for psychosis have both expanded, with goals to better understanding risk and protective factors on the course of illness and inform early intervention efforts. However, some studies have highlighted potential sampling bias among CHR research studies, raising questions about generalizability of findings and inequitable access to early detection and intervention. The current study sought to explore these questions by comparing 94 participants in a CHR longitudinal monitoring study across North America (NAPLS-2) who converted to syndromal psychosis over the course of the study (CHR-CV) to 171 participants who presented for treatment at a localized first-episode psychosis service (FES) after converting. CHR-CV participants were significantly more likely to be White and have a college-educated parent, while FES participants were more likely to be Black and first- or second-generation immigrants. On average, CHR-CV participants were younger at onset of attenuated positive symptoms, had a longer period of attenuated symptoms prior to conversion, and were more likely to be treated with antipsychotics prior to conversion compared to those in FES programs. After controlling for time since conversion, CHR-CV participants had higher global functioning and were less likely to have experienced recent psychiatric hospitalization. Findings suggest that CHR research and FES clinics may be sampling from different populations, although conclusions are limited by inconsistent sampling frames and methods. Integrated early detection that targets defined geographic catchments may deliver more epidemiologically representative samples to both CHR research and FES.

The associations between attenuated psychosis symptoms and functioning in Black and White youth at clinical high-risk for psychosis

Extensive research has demonstrated racial disparities, particularly among Black individuals, in both presentation and course of psychosis spectrum disorders. Few studies, however, have examined racial differences in the clinical high-risk (CHR) phase of illness. It is unclear if functional deficits seen in association with CHR symptoms generalize to marginalized racial groups, or whether race may play a role in the link between symptoms and functioning. In a sample of youth at CHR (N = 46), the present study examined the effect of race (Black and White represented in this sample) on the relation between CHR symptoms and social/role functioning. Race had a moderating effect on the relation between CHR symptoms and social functioning for total positive symptom score (p < .04, f² = 0.10). Although positive symptoms were associated with worse social functioning for White participants, no association was found for Black participants. Follow up analyses indicated suspiciousness was a statistically significant predictor of social functioning for White participants but was unrelated to functioning for Black participants. Results may be indicative of phenomenon experienced by individuals within racial minority groups (e.g., "healthy suspiciousness") or potential measurement validity concerns. Findings further the understanding of racial differences in the CHR phase of illness among White and Black youth and highlight limitations of the existing CHR literature and assessment tools for diverse youth.

Public health primary prevention implemented by clinical high-risk services for psychosis

Clinical High Risk for Psychosis (CHR-P) services have been primarily developed to support young people with attenuated symptoms (indicated prevention). No evidence-based appraisal has systematically investigated to what extent these clinics may implement other preventive approaches. PRISMA 2020-compliant systematic review of Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO, from inception until 14th June 2021, identifying original studies describing public health strategies: (a) service characteristics (configuration of mental health service, outreach, pathways to care); (b) universal interventions (general population); (c) selective interventions targeting CHR-P service-users or family/carers. Public health preventive initiatives were systematically stratified according to core social determinants of mental disorders associated with the 2030 Sustainable Development Goals promoted by the United Nations Member States (UN 2030 SDG) and good mental health outcomes. A total of 66 publications were included, providing data on 13 standalone, 40 integrated, three networks, and six regional or international surveys of CHR-P services across Europe, Asia, Oceania, Africa, North and South America, providing care to >28 M people. CHR-P services implement numerous public health initiatives targeting social and cultural (16 initiatives), economic (seven initiatives), demographic (six initiatives), environmental events (four initiatives) and neighbourhood (three initiatives) UN 2030 SGD determinants of mental disorders. There is additional evidence for CHR-P services promoting good mental health. The main barriers were the lack of resources for expanding public health prevention at a large scale. CHR-P services implement numerous public health prevention initiatives and promotion of good mental health beyond indicated prevention of psychosis.

Expanding the Reach of Research: Quantitative Evaluation of a Web-Based Approach for Remote Recruitment of People Who Hear Voices

Background

Similar to other populations with highly stigmatized medical or psychiatric conditions, people who hear voices (ie, experience auditory verbal hallucinations [AVH]) are often difficult to identify and reach for research. Technology-assisted remote research strategies reduce barriers to research recruitment; however, few studies have reported on the efficiency and effectiveness of these approaches.

Objective

This study introduces and evaluates the efficacy of technology-assisted remote research designed for people who experience AVH.

Methods

Our group developed an integrated, automated and human complementary web-based recruitment and enrollment apparatus that incorporated Google Ads, web-based screening, identification verification, hybrid automation, and interaction with live staff. We examined the efficacy of that apparatus by examining the number of web-based advertisement impressions (ie, number of times the web-based advertisement was viewed); clicks on that advertisement; engagement with web-based research materials; and the extent to which it succeeded in representing a broad sample of individuals with AVH, assessed through the self-reported AVH symptom severity and demographic representativeness (relative to the US population) of the sample recruited.

Results

Over an 18-month period, our Google Ads advertisement was viewed 872,496 times and clicked on 11,183 times. A total amount of US $4429.25 was spent on Google Ads, resulting in 772 individuals who experience AVH providing consent to participate in an entirely remote research study (US $0.40 per click on the advertisement and US $5.73 per consented participant) after verifying their phone number, passing a competency screening questionnaire, and providing consent. These participants reported high levels of AVH frequency (666/756, 88.1% daily or more), distress (689/755, 91.3%), and functional interference (697/755, 92.4%). They also represented a broad sample of diversity that mirrored the US population demographics. Approximately one-third (264/756, 34.9%) of the participants had never received treatment for their AVH and, therefore, were unlikely to be identified via traditional clinic-based research recruitment strategies.

Conclusions

Web-based procedures allow for time saving, cost-efficient, and representative recruitment of individuals with AVH and can serve as a model for future studies focusing on hard-to-reach populations.

Three types of psychotic-like experiences in youth at clinical high risk for psychosis

BACKGROUND

 A fully dimensional model of psychosis implies that psychotic-like experiences (PLEs) connect the entire psychosis spectrum. Three types of self-reported PLEs-persecutory ideation, bizarre experiences, and perceptual abnormalities-are commonly found in the general population. This study assessed the construct, predictive, and incremental validity of self-reported PLEs in youth at clinical high risk for psychotic disorders (CHR).

METHODS

 Self-report data on PLEs (community assessment of psychic experiences; CAPE) were collected from 105 CHR youth (m_age = 19.3). Interview measures of attenuated psychotic symptoms and self-report measures of psychosis proneness, depression, and anxiety were collected at baseline and 12-month follow-up (n = 70 at follow-up). Factor, cross-sectional, and longitudinal analyses examined relationships between study variables.

RESULTS

 Self-reported PLEs were best represented by the same three factors found in the general population: persecutory ideation, bizarre experiences, and perceptual abnormalities. Cross-sectionally, PLEs-particularly persecutory ideation-correlated with interview-rated attenuated psychotic symptoms and self-reported psychosis proneness, depression, and anxiety. Longitudinally, baseline PLEs trended toward predicting 12-month change in positive attenuated psychotic symptoms (r = .29, p_FDR = .058). Incrementally, baseline PLEs predicted 12-month change in positive and disorganized symptoms, when accounting for the effect of baseline positive symptoms and demographics.

CONCLUSIONS

 Three types of PLEs were valid in this CHR sample. Self-reported PLEs may be used not only to screen individuals for inclusion in the CHR classification, but also to characterize individuals within this population. Self-reported PLEs may help to forecast which CHR individuals will progress toward psychotic illness.

Mental Health Services Research Targeting the Clinical High-Risk State for Psychosis: Lessons, Future Directions and Integration with Patient Perspectives

PURPOSE OF REVIEW

We summarize the history of the clinical high-risk stage of psychosis (CHR), current research on this stage and recent critiques of the field, and evaluate current CHR guidelines and frameworks.

RECENT FINDINGS

Following its identification and characterization, CHR services have successfully been developed in North America, Europe, Australia and elsewhere. As reflected in guidelines, these services and their orientation largely emerged as an outgrowth of the framework pioneered by early intervention services for first-episode psychosis. We critically discuss what is known so far about the subjective experience of the CHR syndrome, the meaning of this "unofficial" diagnosis as well as what is known and unknown about the service-related needs. While a range of outstanding questions remain in the field, there is a particular need for patient-oriented work and to investigate the service-related needs of young people at CHR.

Metacognition strengthens the association between neurocognition and attenuated psychosis syndrome: Preliminary evidence from a pilot study among treatment-seeking versus healthy adolescents

BACKGROUND

In a pilot study, we assessed the potential value of deficits at the metacognitive versus the neurocognitive level of functioning for identifying adolescents with attenuated psychotic syndrome (APS).

METHOD

Twenty-two treatment-seeking adolescents with APS, 42 treatment-seeking comparisons, and 34 age-matched healthy comparisons were evaluated using the Prodromal Questionnaire, the Structured Interview for Prodromal Syndromes, and the Mood and Anxiety Symptom Questionnaire. Neurocognitive and metacognitive functioning were assessed in two non-social (verbal memory and executive functioning) and two social (facial emotion perception and theory of mind) cognitive domains. In addition to the standard neurocognitive administration of the tasks, subjects were asked to rate their confidence level on each answer and to choose whether they wanted it "counted" toward their overall task performance score on the task. Choices were rewarded.

RESULTS

As hypothesized, APS among treatment-seeking adolescents was more strongly associated with impaired neurocognition than with impaired metacognition. Likewise, as hypothesized, impaired metacognition was shown to significantly improve the APS prediction beyond the contribution of impaired neurocognition alone, even after controlling for general intellectual ability, negative symptoms, social functioning, and depression.

CONCLUSIONS

These results suggest that metacognitive monitoring and control play a strengthening role in the association between neurocognition and APS. One possible explanation is that metacognition serves as an indicator of insight into the condition, accounting for differences in insight not explained by neurocognition alone. However, further research with larger samples that include non-treatment seeking individuals, established measures of insight, and follow-up data is required to assess this possibility.

Does an integrated outreach intervention targeting multiple stages of early psychosis improve the identification of individuals at clinical high risk?

AIMS

To explore the impact of a targeted case identification intervention, with training and education regarding first-episode psychosis and clinical high-risk syndromes, on the referral and identification of those at high risk.

METHODS

Using a historical control design, referral information from pre-intervention and post-intervention periods was collected via administrative data and clinician notes from a catchment-based early psychosis service.

RESULTS

A significant increase in the number of referrals sent to the service's clinical high-risk unit was observed following the intervention (P = 0.01). The proportion of referrals eligible was significantly higher post-intervention (P = 0.03), with the majority (26/44, 59.1%) referred via the first-episode psychosis service unit.

CONCLUSIONS

An integrated outreach intervention for both first-episode psychosis and the clinical high-risk state was effective in increasing referrals of eligible cases to the service's at-risk unit. Rather than being stage-specific, targeted case identification strategies and service integration should span across the early stages of psychosis.

'At risk mental state' clinics for psychosis - an idea whose time has come - and gone!

At Risk Mental State (ARMS) clinics are specialised mental health services for young, help-seeking people, thought to be at ultra-high risk of developing psychosis. Their stated purpose is to reduce transitions from the ARMS state to clinical psychotic disorder. Reports of ARMS clinics provide 'evidence-based recommendations' or 'guidance' for the treatment of such individuals, and claim that such clinics prevent the development of psychosis. However, we note that in an area with a very well-developed ARMS clinic (South London), only a very small proportion (4%) of patients with first episode psychosis had previously been seen at this clinic with symptoms of the ARMS. We conclude that the task of reaching sufficient people to make a major contribution to the prevention of psychosis is beyond the power of ARMS clinics. Following the preventative approaches used for many medical disorders (e.g. lung cancer, coronary artery disease), we consider that a more effective way of preventing psychosis will be to adopt a public health approach; this should attempt to decrease exposure to environmental factors such as cannabis use which are known to increase risk of the disorder.

Core beliefs in healthy youth and youth at ultra high-risk for psychosis: Dimensionality and links to depression, anxiety, and attenuated psychotic symptoms

Cognitive theory posits that core beliefs play an active role in developing and maintaining symptoms of depression, anxiety, and psychosis. This study sought to comprehensively examine core beliefs, their dimensionality, and their relationships to depression, anxiety, and attenuated psychotic symptoms in two groups of community youth: a group at ultrahigh risk for psychosis (UHR; n = 73, M age = 18.7) and a matched healthy comparison group (HC; n = 73, M age = 18.1). UHR youth reported significantly more negative beliefs about self and others, and significantly less positive beliefs about self and others. HC youth rarely endorsed negative self-beliefs. Exploratory factor analyses found that HC negative self-beliefs did not cohere as a single factor. We hypothesized specific links between core beliefs and symptoms based on cognitive models of each disorder, and tested these links through regression analyses. The results in the HC group were consistent with the proposed models of depression and anxiety. The results in the UHR group were consistent with proposed models of depression and negative psychotic symptoms, somewhat consistent with a proposed model of positive psychotic symptoms, and not at all consistent with a proposed model of anxiety. These findings add to a growing developmental literature on core beliefs and psychopathology, with important clinical implications.

Disturbances of the Basic Self and Prodromal Symptoms Among Young Adolescents From the Community: A Pilot Population-Based Study

BACKGROUND AND GOAL

Recent findings have provided preliminary support for the notion that basic self-disturbances (SD) are related to prodromal symptoms among nonpsychotic help-seeking adolescents. As a sizable proportion of adolescents who are at risk do not seek help, this study attempts to assess the extent to which these findings can be generalized to the entire population of adolescents who are at risk for psychosis.

METHOD

The concurrent relationship between SD and prodromal symptoms was explored in a sample of 100 non-help-seeking adolescents (age 13-15) from the community. SD were assessed with the Examination of Anomalous Self-Experience (EASE); prodromal symptoms and syndromes were assessed with the Structured Interview for Prodromal Syndromes (SIPS); psychosocial functioning was assessed with the "Social and Role Global Functioning Scales"; and level of distress with the Mood and Anxiety States Questionnaire (MASQ).

RESULTS

SD significantly correlated with sub-clinical psychotic symptoms (r = .70, P < .0001). This correlation was significantly stronger than those of SD with mood symptoms and social functioning. Finally, SD was the single best concurrent predictor of prodromal symptoms and syndromes.

CONCLUSIONS

These results provide preliminary support for the generalizability of the association between SD and prodromal symptoms for the entire population of adolescents who are clinically at high risk for psychosis. In addition, they further support the notion that this association is both specific and unique.

Anomalous self-experiences and their relationship with symptoms, neuro-cognition, and functioning in at-risk adolescents and young adults

Empirical and theoretical studies support the notion that anomalous self-experience (ASE) may constitute a phenotypic aspect of vulnerability to schizophrenia, but there are no studies examining the relationship of ASE with other clinical risk factors in a sample of ultra-high risk (UHR) subjects. The aim of the present study was to explore the relationship between ASE, prodromal symptoms, neurocognition, and global functioning in a sample of 45 UHR adolescents and young adults (age range 15-25years) at first contact with Public Mental Health Services. Prodromal symptoms and global functioning were assessed through the SIPS interview. ASE was evaluated through the Examination of Anomalous Self-Experience (EASE); for neurocognition, we utilized a battery of tests examining seven cognitive domains as recommended by the Measurement And Treatment Research to Improve Cognition in Schizophrenia. In the UHR group, higher levels in two domains of the EASE (stream of consciousness and self-awareness) were found in comparison with help-seeking subjects. Correlational analysis corrected for possible confounding variables showed a strong association (p>0.001) between higher EASE scores and global functioning. A principal factor analysis with Varimax rotation yielded a two-factor solution, jointly accounting for 70.58% of the total variance in the UHR sample. The first factor was comprised of SOPS domains, while the second was comprised of EASE-total, EASE-10, and GAF variables. Our findings provide support for the notion that disorders of self-experience are present early in schizophrenia and are related to global functioning. As such, they may constitute a potential marker of risk supplementing the UHR approach.

N-acetylcysteine prevents increased amphetamine sensitivity in social isolation-reared mice

Treating individuals at risk to develop schizophrenia may be strategic to delay or prevent transition to psychosis. We verified the effects of N-acetylcysteine (NAC) in a neurodevelopmental model of schizophrenia. C57 mice were reared in isolation or social groups and treated with NAC from postnatal day 42-70; the locomotor response to amphetamine was assessed at postnatal day 81. NAC treatment in isolated mice prevented the hypersensitivity to amphetamine, suggesting neuroprotection relevant to striatal dopamine. Considering its safety and tolerability profile, complementary studies are warranted to further evaluate the usefulness of NAC to prevent conversion to schizophrenia in at-risk individuals.

Prodromal psychosis detection in a counseling center population in China: an epidemiological and clinical study

BACKGROUND

To investigate through a two-stage clinic-based screening, the frequency and clinical features of risk for psychosis syndromes in a Chinese help-seeking sample.

METHOD

2101 consecutive new patients ages 15-45 were recruited at their first visit to the Shanghai Mental Health Center (SMHC) and screened with the Prodromal Questionnaire-Brief version (PQ-B) and questions about genetic risk. The Structured Interview for Prodromal Syndromes (SIPS) was administered to a sub-sample to estimate rates of psychosis and clinical high risk (CHR) for psychosis syndromes.

RESULTS

The frequency estimate of CHR syndromes in the total sample was 4.2%. Among 89 CHR patients, more than two-thirds met the criteria for Attenuated Positive Symptom Syndrome (APSS); and nearly a quarter met the criteria for Genetic Risk and Deterioration Syndrome (GRDS). The frequency of CHR syndromes peaked between the ages of 16 and 21years old and declined with subsequent age. The mean total and distress scores on the PQ-B in subjects with APSS and psychosis were significantly higher than in individuals with GDRS and patients without psychosis or CHR. High frequencies and strong correlations were found among some positive and non-specific symptoms in SIPS interviews. Among the 53 CHR participants who were followed-up for two years, 14 (26.4%) converted to psychosis. Of the non-converters, 53.8% were diagnosed with Axis I disorders.

CONCLUSIONS

This two stage screening method can enhance detection of Chinese CHR patients in clinical settings. The validity of the procedures for detecting CHR is supported by rates of transition to psychosis and of non-converter Axis I disorders that are comparable to those reported in meta-analyses.

Pathways to care in subjects at high risk for psychotic disorders - a European perspective

Evidence-based decisions on indicated prevention in early psychosis require large-scale studies on the pathways to care in high-risk subjects. EPOS (The European Prediction of Psychosis Study), a prospective multi-center, naturalistic field study in four European countries (Finland, Germany, The Netherlands and England), was designed to acquire accurate knowledge about pathways to care and delay in obtaining specialized high risk care. Our high risk sample (n=233) reported on average 2.9 help-seeking contacts, with an average delay between onset of relevant problems to initial help-seeking contact of 72.6 weeks, and between initial help-seeking contact and reaching specialized high risk care of 110.9 weeks. This resulted in a total estimated duration of an unrecognized risk for psychosis of 3 ½ years. Across EPOS EU regions, about 90% of care pathway contacts were within professional health care sectors. Between EPOS regions, differences in the pathways parameters including early detection and health-care systems were often very pronounced. High-risk participants who later made transition to a full psychotic disorder had significantly longer delays between initial help-seeking and receiving appropriate interventions. Our study underlines the need for regionally adapted implementation of early detection and intervention programs within respective mental health and health care networks, including enhancing public awareness of early psychosis.

Neurocognitive performance of a community-based sample of young people at putative ultra high risk for psychosis: support for the processing speed hypothesis

INTRODUCTION

A wide variety of neurocognitive deficits have been reported for help-seeking individuals who are at clinical or ultra high risk for psychosis based on fulfilling set criteria for prodromal syndromes/at risk mental states. We wished to extend this research by conducting the first population-based assessment of prodromal syndromes and associated neurocognition.

METHODS

A sample of 212 school-based adolescents were assessed for prodromal syndromes using the criteria of prodromal syndromes from the Structured Interview for Prodromal Syndromes. The MATRICS consensus neurocognitive battery was used to assess cognitive functioning in this sample.

RESULTS

A total of 8% of the population sample of adolescents met criteria for a prodromal syndrome. These adolescents performed significantly more poorly than controls on two tests of processing speed-Trail-Making Test Part A, F=4.54, p < .01, and the Brief Assessment of Cognition in Schizophrenia Symbol Coding task, F=8.26, p < .0001-and on a test of nonverbal working memory-the Wechsler Memory Scale Spatial Span task, F=3.29, p < .05.

CONCLUSIONS

Adolescents in the community who fulfil criteria for prodromal syndromes demonstrate deficits on a number of neurocognitive tasks. Deficits are particularly pronounced in symbol coding performance, supporting processing speed as a central deficit associated with psychosis risk.

Disturbances of basic self and prodromal symptoms among non-psychotic help-seeking adolescents

BACKGROUND

The goal of this study was to explore the notion that anomalies of self-experience (ASE) are a core, 'not-yet-psychotic' clinical phenotype of emerging schizophrenia and its spectrum. Method To accomplish this goal, we examined the relationship between ASE and commonly accepted risk markers in a sample of 87 help-seeking, non-psychotic adolescents (aged 14-18 years). ASE were assessed with the Examination of Anomalous Self-Experience (EASE), subclinical psychotic symptoms were assessed with the Prodromal Questionnaire and the Structured Interview for Prodromal Syndromes, deterioration in psychosocial functioning was assessed with the Social and Role Functioning Scales, and level of distress with the Mood and Anxiety Symptoms Questionnaire.

RESULTS

About 82 participants completed the entire EASE interview. The number of participants who reported ASE at a clinically meaningful level (n = 18, 22%) was smaller than that who met diagnostic criteria for a prodromal syndrome (n = 28, 34%). The degree of overlap between the two conditions was moderate but statistically significant (χ2 (1) = 7.01, p = 0.008). An exploratory factor analysis revealed that ASE load on a different factor than prodromal symptoms and deterioration in functioning, but that there is a moderate correlation between the three factors.

CONCLUSIONS

These results suggest that ASE are prevalent among non-psychotic help-seeking adolescents, yet at a considerably lower rate than prodromal symptoms. In addition, they suggest that ASE and prodromal symptoms constitute distinct but moderately related dimensions of potential risk. Taken together, they provide preliminary support for the clinical usefulness of supplementing and refining the methods of early detection of risk with assessment of ASE.

Pathways to care for those at clinical high risk of developing psychosis

AIM

Understanding the pathways to care is a prerequisite for early detection in first-episode patients with psychosis. Less in known about the pathways to care for individuals at clinical high risk for psychosis.

METHODS

A sample of 35 clinical high risks for psychosis individuals were administered a semistructured questionnaire inquiring about pathways to care.

RESULTS

The majority of contacts were made to general practitioners (32.8%). Various symptoms of concern were reported among the sample, the most common being depression (15.9%) followed by anxiety (11.0%). Delusions/paranoia were the most frequent symptoms associated with successful referral to contacts (14.3%).

CONCLUSION

Education on the pathway to successful access to care and treatment in a putatively prodromal for psychosis group of individuals is valuable information that can potentially aid in a faster discovery of these individuals and their access to treatment and care.

The development of the Content of Attenuated Positive Symptoms Codebook for those at clinical high risk of psychosis

Examining the content of psychotic symptoms may be relevant for understanding symptom development particularly in those in the very early stages of psychosis. The Content of Attenuated Positive Symptoms codebook was developed as a means to overcome methodological issues in the current literature. Three separate samples at clinical high risk of psychosis were used to develop, modify and finalize the codebook. The inter-rater reliability was moderate to excellent. Specific content items were consistently endorsed across samples. This codebook offers a reliable way to assess content in the clinical high-risk population.

Detection of people at risk of developing a first psychosis: comparison of two recruitment strategies

OBJECTIVE

Better recruitment strategies are needed to improve the identification of people at ultra-high risk of developing psychosis. This study explores the effectiveness of two recruitment strategies: a screening method in a consecutive help-seeking population entering secondary mental health services for non-psychotic problems vs. a population referred to the diagnostic center of an early-psychosis clinic.

METHOD

From February 2008 to February 2010, all general practitioner and self-referrals (aged 18-35 years) to the secondary mental healthcare service in The Hague and Zoetermeer were screened with the Prodromal Questionnaire; patients who scored above the cutoff of 18 and had a decline in social functioning were assessed using the Comprehensive Assessment of At-Risk Mental States (CAARMS). All referrals (aged 14-35 years) to the diagnostic center in Amsterdam were also assessed with the CAARMS.

RESULTS

The screening detected a three-fold higher prevalence of at-risk mental states: these subjects were older and more often female. manova showed significantly higher scores for the screened population on depression, social anxiety, distress with positive symptoms, and a higher rate of transition to psychosis within 12 months.

CONCLUSION

The screening method detects more patients with at-risk mental states than the referral method. The latter method is biased to young male patients in an earlier prodromal stage and a lower transition rate.

Identification and characterization of prodromal risk syndromes in young adolescents in the community: a population-based clinical interview study

While a great deal of research has been conducted on prodromal risk syndromes in relation to help-seeking individuals who present to the clinic, there is a lack of research on prodromal risk syndromes in the general population. The current study aimed first to establish whether prodromal risk syndromes could be detected in non-help-seeking community-based adolescents and secondly to characterize this group in terms of Axis-1 psychopathology and general functioning. We conducted in-depth clinical interviews with a population sample of 212 school-going adolescents in order to assess for prodromal risk syndromes, Axis-1 psychopathology, and global (social/occupational) functioning. Between 0.9% and 8% of the community sample met criteria for a risk syndrome, depending on varying disability criteria. The risk syndrome group had a higher prevalence of co-occurring nonpsychotic Axis-1 psychiatric disorders (OR = 4.77, 95% CI = 1.81-12.52; P < .01) and poorer global functioning (F = 24.5, df = 1, P < .0001) compared with controls. Individuals in the community who fulfill criteria for prodromal risk syndromes demonstrate strong similarities with clinically presenting risk syndrome patients not just in terms of psychotic symptom criteria but also in terms of co-occurring psychopathology and global functioning.

Maladaptive schemas as a mediator between social defeat and positive symptoms in young people at clinical high risk for psychosis

AIM

Social defeat may be the mechanism that links past social adversities with the development of psychosis. In depression research, it is accepted that adverse early social experiences can lead to enduring cognitive vulnerabilities, characterized by negative schemas about the self and others. The aim of this study was to examine whether negative beliefs about the self and others link social defeat to early signs of psychosis.

METHODS

Data from a sample of individuals at high risk for developing psychosis (n = 38) were assessed using measures of social defeat and schemas.

RESULTS

High levels of social defeat and negative evaluations of the self and others were displayed. Negative beliefs mediated the relationship between social defeat and early symptoms, offering some support for the notion that maladaptive self-beliefs play a role in the onset of psychosis.

CONCLUSIONS

These results have implications for prevention because these maladaptive schemas are malleable factors for which we have effective psychological interventions.

Treating young individuals at clinical high risk for psychosis

BACKGROUND

Typically, studies investigating those at clinical high risk for psychosis have focused on predictors of conversion and treatments that might prevent conversion to full-blown psychosis. Few studies have followed those who do not go on to develop a psychotic illness.

METHODS

Participants were 48 young people who were at risk for developing psychosis based on the Structured Interview for Prodromal Symptoms criteria and participated in a treatment programme where they were offered up to 6 months of psychosocial treatment and psychiatric management. Attenuated psychotic symptoms, negative symptoms, depression, anxiety, social functioning, alcohol and drug use, and meta-cognitive beliefs were assessed at baseline, 6, 12 and 18 months. Personality characteristics were assessed at baseline. Medication use was tracked and psychiatric visits were logged over the 18-month study period.

RESULTS

On average, participants attended 12 sessions of psychosocial treatment and had one meeting with the psychiatrist every 6 months. Only 24% were ever prescribed any psychotropic medications, and antipsychotics were not used. Significant improvements were found over time in attenuated positive symptoms, negative symptoms, depression, anxiety, meta-cognitions and social functioning with most improvement occurring in the first 6 months. There was no change in the level of substance use. For personality assessment, participants generally scored high on neuroticism and openness and had low scores on extraversion, agreeableness and conscientiousness.

CONCLUSION

With minimal treatment and no antipsychotics, young people who present as being at risk for developing a psychotic disorder demonstrate clinical improvement over time. However, a few continued to have the liability of ongoing attenuated psychotic symptoms.

A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis

BACKGROUND

There has been increasing interest in early detection during the prodromal phase of a psychotic disorder. To date a few treatment studies have been published with some promising results for both pharmacological treatments, using second generation antipsychotics, and psychological interventions, mainly cognitive behavioral therapy. The purpose of this study was to determine first if cognitive behavioral therapy (CBT) was more effective in reducing the rates of conversion compared to a supportive therapy and secondly whether those who received CBT had improved symptoms compared to those who received supportive therapy.

METHOD

Fifty-one individuals at clinical high risk of developing psychosis were randomized to CBT or a supportive therapy for up to 6 months. The sample was assessed at 6, 12 and 18 months post baseline on attenuated positive symptoms, negative symptoms, depression, anxiety and social functioning.

RESULTS

Conversions to psychosis only occurred in the group who received supportive therapy although the difference was not significant. Both groups improved in attenuated positive symptoms, depression and anxiety and neither improved in social functioning and negative symptoms. There were no differences between the two treatment groups. However, the improvement in attenuated positive symptoms was more rapid for the CBT group.

CONCLUSIONS

There are limitations of this trial and potential explanations for the lack of differences. However, both the results of this study and the possible explanations have significant implications for early detection and intervention in the pre-psychotic phase and for designing future treatments.

Using the Brief Core Schema Scales with Individuals at Clinical High Risk of Psychosis

Background: The Brief Core Schema Scales (BCSS) were developed to provide a theoretically coherent self-report assessment of schemata concerning self and others in psychosis. They provide a more useful measure of schemata about self and others than traditional measures of self-esteem. Aims: The aim of this study was to determine if these scales would be useful in a sample of individuals who are at clinical high risk of psychosis to help identify targets for intervention. Method: Thirty-eight individuals who are at high risk for psychosis were administered the Scale of Prodromal Symptoms, the Calgary Depression Scale, the Brief Core Schema Scales and the Young Schema Questionnaire–short version. Results: Results suggested that these scales are appropriate for this population and that negative evaluations of the self and others were significantly associated with attenuated psychotic symptoms and, in particular, suspiciousness.